Guide to nMRCGP for Clinical SupervisorsThe Guide for Clinical Supervisors has been produced by the RCGP in consultation with NACT and COGPED to explain the model of supervision, to provide a brief introduction to assessment and to give guidance on what a consultant providing clinical supervision for GP trainees is expected to do.

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Are you a hospital consultant visiting this page? If so, we are absolutely delighted that you are here and in your interest in GP training. This page is devoted to hospital consultants like you who want to become more familiar with GP training and all the assessments that GP trainees have to do. In fact, this page will furnish you with resources to help do the assessments like the way they are meant to be done. Doing so may even help you do similar assessments with your own specialty trainees better! If you have any suggestions on how we might improve these pages for other consultants like you, please drop our TPD Ramesh Mehay a line at [email protected] .

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GP training is currently set at 3 years. Our trainees, like most hospital specialty trainees, are called Specialty Trainees and the three years referred to as St1, ST2 and ST3.

Most of our GP trainees in hospital posts are either at ST1 or ST2 level. ST3s are usually based in GP posts for the whole year.

During the three years, the GP trainee has to complete the MRCGP – which is the national licensing assessment for General Practice. In this, the GP trainee has to do continuous assessments – called Work Place Based Assessments. They also have to do two exams – one is a multiple choice question paper (called AKT – Applied Knowledge Test) and the other is an OSCE style exam called the CSA (Clinical Skills Assessment) – they only get four tries at successfully completing these.

A log of all these assessments are kept in their own electronic folder called the ePortfolio. In the ePortfolio, they also have to record evidence of their learning – from specific patient cases, from teaching and tutorials, from significant events, from audit and other projects and so on.

During the 3 years, they have regularly scheduled meetings with their Clinical and Educational Supervisors (who are different people and have different roles).

After ST3 (i.e. 3 years), providing they’ve (i) passed all the exams, (ii) their assessments show evidence for competencies, (iii) their ePortfolio looks good and (iv) their Educational and Clinical Supervisors are happy, they can apply for their CCT (Certificate of Completion of Training) – which grants them permission to practise independently as GPs.

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The curriculum covers the knowledge and skills that all GP trainees need to learn in order to deliver the highest quality standards of patient care. It won’t surprise you to hear that it’s a large document – after all, General Practice is a broad specialty which encompasses a number of other specialties. To make the GP curriculum easier to understand, it is divided into a number of Curriculum Statement Headings. There’s a section which focuses on the GP consultation (which is at the heart of being a GP). Others focus on the day to day aspects of being a GP and organisational management. And finally, others concentrate of various clinical specialties. Please familiarise yourself with the curriculum. The more you look at it, the more familiar with it you will become.

There’s quite a number of different types of assessments for the MRCGP. They all have acronyms which can make it look more complicated than it really is. As GP Trainers, we have had extensive training on how to do these assessments. We’ve had repeated opportunities for practising them and for benchmarking ourselves against our colleagues. It is really unfortunate that most hospital consultants have not been given the same level and depth of training we have had from our Deanery. We hope to pass on some of what we have learnt to you through these pages. For simplicity’s sake, we’ll only cover the assessments YOU will be involved in. You’ll be glad to know that of the 12 types of WPBA assessments, you only need to really get to grips with 5 of them.

It’s really important to grasp a good understanding of what each of these assessments is about because if you carry them out the way they are meant to be done, you will be able to define more precisely and reliably what bits a trainee is good at and what areas they need to focus and develop. And the good thing is that it is very likely that specialty trainees for your own clinical specialty will have to do these assessments too – if not now, in the near future! So – by covering them in some detail here, you’ll not only be training yourself up for doing assessments for GP training, but also for doing assessments for your own specialty. And let’s not forget the Foundation Year docs who already have to do them. The skills you will learn here are transferable!

Click on an assessment below to read more about it. Each has it’s own web page on which you will find some really useful forms and practical guidance (especially in the ‘Downloadable Resources’ box on each page).

You can find very detailed information on the MRCGP and it’s individual bits on our Royal College’s website: www.rcgp.org.uk

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Some of the Work-Place Based Assessments are graded in slightly different ways. This is illustrated in the table below. Although this might seem confusing at first, we hope you can see commonalities. After the table, we will attempt to demystify the meaning behind some of the ‘grades’.[hr]

Insufficient Evidence (IE) means you are Unable to Grade (UG). This might be because you actively decided not to concentrate on a particular competency because you wanted to concentrate on some of the others. Or perhaps the material being assessed wasn’t ‘the best’ for this particular competency. Clearly, if there are repeatedly ‘Insufficient Evidence’ grades for a particular competency for a particular set of assessments, then the trainees needs to be encouraged to actively find material that will demonstrate it.

Below Expectations means that the trainee (for a particular competency) has performed below what you would have expected from a trainee at similar stage of training. Therefore, they Need Further Development (NFD).

Borderline (B) means that you’re not quite sure whether the trainee (for a particular competency) is performing okay or not when compared to a typical trainee at a similar stage of training. Clearly, they still Need Further Development (NFD).

Meets Expectations (ME) means that the trainee (for a particular competency) has performed on par with what you would have expected from a trainee at similar stage of training. This is not to say they are competent for licensing – they will still have needs for further development until they get to that stage that most certified doctors are at. All you are saying is that they Need Further Development (NFD) but that they are progressing at the expected rate.

Above Expectations (AE) means that the trainee (for a particular competency) has performed above what you would have expected from a trainee at similar stage of training. They often still have more to learn before they can be deemed safe to practise independently as certified doctors. So, with this grade, all you are saying is that whilst they still have Needs Further Development (NFD), they are progressing exceptionally well – greater than the average trainees.

Competent For Licensing means that you believe that there is evidence to show that the trainee (for a particular competency) has performed to the level of what you would expect from a doctor CERTIFIED to practise independently as a general practitioner.

Excellent (E) means that the trainee isn’t just competent to perform at the level expected of a certified doctor allowed to practise independently as a GP but that they perform at an exceptionally high level (or even mastery).

During their ST1 years, most trainees should be scoring at Borderline, Meets Expectations or Needs Further Development levels most of the time. During the ST2 year, trainees should be scoring at the Meets Expectations, Needs Further Development and occasionally Competent levels as they gradually acquire the necessary knowledge, skills and attitudes for the various professional competencies. And during ST3, they should mostly be hitting Competent levels with the occasional Excellent here and there.

Please note:

Above Expectations (AE) and Excellent (E) grades should not be awarded in a ‘willy nilly’ sort of way. They should be awarded when you are in absolute awe of the trainee’s performance for a particular competency.

Don’t be afraid of awarding Needs Further Development during their early years because:

At the ST1 and ST2 stages, trainees have further developmental needs,

Needs Further Development is the grade that is expected at the ST1 and 2 stages for many of the competencies and

At first glance, external assessors may not take your assessments seriously if everything, especially at the early stages of a trainee’s career, is marked as Competent or Excellent. They’ll be asking themselves ‘How can someone so early on be so competent and good?’.

Trainees may expect you to award a Competent or Excellent because this is probably what they’ve been usually given in the Foundation years of their training. They may well be disappointed with a Needs Further Development grade. Please take a moment to explain things to them. Explain that Needs Further Development is NOT a failure or fail grade. It simply means that they need to work on a particular area to become stronger in it. This is what the assessment system is designed to do, so that further training experiences can be directed toward their developmental needs. Explain to them that all of us, as human beings, have ‘needs further development’ in all aspects of our lives. Also take a moment to explain the three reasons listed above. Doing it in this way will help get you both onto the same wavelength and therefore lessen their dissatisfaction with your grading. However, that’s not to say you should go the other way and become a complete hawk by marking all 12 Professional Competencies as Needs Further Development in the ST1 or 2 years – that in itself can be demotivating. You need to provide a balance which also portrays and accuratepicture of where the trainee is currently at. At the ST3 stage (where most trainees will be in a GP post), GP Trainers are expected to use their personal experience as a GP to judge whether the evidence for each competence area and the totality of evidence indicate that the GP trainee is ready for independent practice. Trainees should respect this decision.

Because the MRCGP is the licensing exam for all trainees wanting to become GPs, all the core components have to be done in a timely fashion. [highlight]So, if a trainee keeps badgering you to do (say) a CBD assessment on them, please don’t ignore them or put it off.[/highlight] In fact, it is we (the Training Programme Directors) who have asked our trainees to badger you. Please don’t be offended by this. The problem is that if they don’t get them done in a timely way, they won’t be allowed to progress onto their next ST year. It really does affect them that much. We realise that Hospital Consultants lead very busy lives and assessments like the CBDs need time. Please can we suggest to you that you make a specific date and time to make sure these assessments happen? How about something like “Let’s make a date for that; how about next week on Tues morning after the ward round?”?.

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Yes, but only if you have trained them how to do it properly. At the moment, we are seeing too many GP trainees being assessed by specialist registrars who have not been trained in what the competencies mean or how to carry out the assessments. The Royal College would deem this unacceptable and it is against the rules. No surgeon in their right mind would consider allowing their trainee to do say an appendectomy without training them up first……the same applies to these assessments for General Practice training. They are important assessments which dictate whether a trainee is safe with patients and we must not forget that.

In the early stages of training it is unlikely that the GP trainee will be able to provide evidence for the readiness to practise. A trainee’s readiness to practise is determined by evaluating their performance again 12 nationally set Professional Competencies. These are listed below. [highlight]The standard against which the GP trainee is judged is always the level of competence expected of a doctor who is certified to practise independently as a general practitioner (i.e. a qualified GP). [/highlight]This standard is used throughout the three years of training. This means that in the first two years of training the trainee is being judged against the standard they should have reached at the end of training. Inevitably there will be less evidence from the application of the WPBA tools in the first two years of training, and more developmental needs will be identified. This is what the assessment system is designed to do, so that further training experiences can be directed toward the developmental needs of trainees.

Therefore, as a trainee moves through training, they will gradually accrue more and more knowledge, skills and attitudes for the 12 professional competencies (each one has its own unique set of knowledge, skills and attitudes). A trainee at the ST1 stage may not have much evidence in their ePortfolio to say that they are competent in many of the 12 professional competencies, and that is okay – in fact, that is what is EXPECTED! However, as they move through the ST years, they will gradually build a richer base of evidence to deem them more and more satisfactory in an incremental way. Towards the ends of ST3, their should be strong evidence for competency across all 12 nationally set Professional Competencies. This progressive build up of evidence for the 12 professional competencies is called competency progression.

How will trainees know what are their strengths and weaknesses so that they can build on their weaknesses and provide a broader and richer evidence set?The trainee will hopefully be able to identify their strengths and weaknesses simply by reviewing whatever is in their ePortfolio. Clearly, for this to be reliable depends on them actively (and regularly) engaging with the ePortfolio and capturing their learning experiences within it. They will be aided in this analysis through their Educational Supervision meetings. Their Educational Supervisor will meet at least once during every post and together the structured evidence in the ePortfolio will be considered against the Professional Competency framework in order to identify strengths and weaknesses; this will help them develop a learning plan designed to enable the trainee to collect more evidence of competence and to build up a richer picture of readiness for practice.

We will repeat this message again….’Needs Further Development’ is okay and is not a signal of failure. In fact, it’s the grade expected for many of the 12 Professional Competencies during the early years.Trainees may expect you to award a Competent or Excellent because this is probably what they’ve been usually given in the Foundation years of their training. They may well be disappointed with a Needs Further Development grade. Please take a moment to explain things to them. Explain that Needs Further Development is NOT a failure or fail grade. It simply means that they need to work on a particular area to become stronger in it. This is what the assessment system is designed to do, so that further training experiences can be directed toward their developmental needs. Explain to them that all of us, as human beings, have ‘needs further development’ in all aspects of our lives. Also explain that this is the grade EXPECTED during the early years and get them to understand competency progression. Get them to see how silly it looks to label a trainee as being competent in everything at the start of their training programme. Ask them – what would be the point of the training programme? Doing it in this way will help get you both onto the same wavelength and therefore lessen their dissatisfaction with your grading. However, that’s not to say you should go the other way and become a complete hawk by marking all 12 Professional Competencies as Needs Further Development in the ST1 or 2 years – that in itself can be demotivating. You need to provide a balance which also portrays and accuratepicture of where the trainee is currently at. At the ST3 stage (where most trainees will be in a GP post), GP Trainers are expected to use their personal experience as a GP to judge whether the evidence for each competence area and the totality of evidence indicate that the GP trainee is ready for independent practice. Trainees should respect this decision.

In this section, we will attempt to explain why we need an ePortfolio and what it’s all about. As you’ve probably noticed, a record of personal development and experience is becoming mandatory for all doctors. It provides evidence that training has taken place and allows the doctor to reflect on a range of learning opportunities. By making use of the full capability of electronic systems, the ePortfolio can be used to record, monitor and manage a GP trainee’s learning all in one place. By providing a structure for documenting the evidence harvested through Work-Place Based Assessment (WPBA) tools, the ePortfolio helps to ensure that judgements about the GP trainee’s progress and achievement are based on a clear, systematically recorded picture of competence. Above all else the Trainee ePortfolio is where the GP trainee records their learning in all its forms and settings. Its prime function is to be an educational tool that will record and facilitate the management of the journey of clinical and personal development through learning.

At the beginning of specialty training, when a GP trainee registers with the Royal College of GPs (RCGP), they will be given access to the RCGP Trainee ePortfolio which will be used throughout the training period, in both hospital posts and primary care. It is accessed and updated through the internet.

Although the ePortfolio belongs to the GP trainee, key parts of it are accessible to the GP Trainer, Hospital Consultant, Educational Supervisor and deanery administrators through a permissions system.

The trainee will use it to record their learning experiences and reflections.

The trainee’s Educators (like the Clinical Supervisor, Educational Supervisor, Training Programme Director and so on) will use it to record things like the trainee’s assessments, progress and reviews.

It must be used at all stages of training to document the assessments. The assessments recorded in the Trainee ePortfolio will be drawn from performance and evaluation taking place in the real situations in which doctors work.

The Trainee ePortfolio should also be used to record and validate naturally occurring evidence against the competence framework. This is evidence which occurs in the course of practice and which illustrates the GP trainee’s competence. For example, the trainee may do an evidence review on a specific topic and present it to a practice meeting. This might be taken as evidence of data gathering and interpretation, or communication skills. Evidence that a trainee is late for ward rounds on a regular basis might be discussed with the them and recorded under teamwork. Naturally occurring evidence needs to be validated by the Clinical Supervisor (GP trainer in GP posts, Hospital Consultant in hospital posts).

All entries can be tagged to the competence areas so that an overall picture of competence is easily accessed.

It also allows competence in areas such as team-working to be appraised in a manner which cannot be done by the AKT and CSA.

The ePortfolio will detail achievements in the various MRCGP exams – namely, AKT and CSA.

It has a diary and a mailbox. It also contain links to learning resources that are being developed by the RCGP and has a personal area where individuals can save files, documents, certificates of learning and other digital materials.

In general, the ePortfolio might be described as the “glue” which holds the curriculum learning and assessment together.

Throughout training, the GP trainee will have one Educational Supervisor and several Clinical Supervisors. They will have regular reviews with both. However, don’t confuse the two. Each aims to do different things as illustrated in the table below. Clinical Supervisors are qualified specialists who have responsibility for the day-to-day supervision, training and assessment of trainees who are doing a placement in their specialty. In a GP post, the Clinical Supervisor is the GP Trainer. In a hospital post, the Clinical Supervisor is the Hospital Consultant. In an integrated post (e.g. combined Eyes & ENT job), then they will have a clinical supervisor for each specialty.

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The Gold Guide (section 4.27) requires that:

Each trainee should have a named Clinical Supervisor for each placement, usually a senior doctor, who is responsible for ensuring that appropriate clinical supervision of the trainee’s day-to-day clinical performance occurs at all times, with regular feedback.

All clinical supervisors should:

Understand their responsibilities for patient safety.

Be fully trained in the specific area of clinical care.

Offer a level of supervision necessary to the competences and experience of the trainee and tailored for the individual trainee.

Ensure that no trainee is required to assume responsibility for or perform clinical, operative or other techniques in which they have insufficient experience and expertise.

Ensure that trainees only perform tasks without direct supervision when the clinical supervisor is satisfied that they are competent so to do; both trainee and clinical supervisor should at all times be aware of their direct responsibilities for the safety of patients in their care.

Consider whether it is appropriate (particularly out of hours) to delegate the role of clinical supervisor to another senior member of the healthcare team. In these circumstances the individual must be clearly identified to both parties and understand the role of the clinical supervisor. The named clinical supervisor remains responsible and accountable for the care of the patient and the trainee.

Be appropriately trained to teach, provide feedback and undertake competence assessment of the trainees in the specialty.

Be trained in equality and diversity and human rights best practice.

Responsibilities: Clinical supervisors oversee the day-to-day work of the trainee during that placement. They are expected to:

Hold formative meetings with their trainee at the beginning, middle and end of their placement.

Use WPBA assessment tools as learning opportunities, formative assessments and to provide evidence towards the record of competence progression collected in the trainee’s eportfolio.

Complete a Clinical Supervisors Report (CSR) at the end of the placement. If a trainee is in an integrated post working concurrently in more than one specialty, then each clinical supervisor will complete a CSR.[/toggle]

To clarify the educational attendance requirements for GP trainees: It is an absolute requirement for them to attend the equivalent of 70% of possible half-day release sessions. (This means 70% of the total number of sessions, not 70% of those which do not fall while they are on annual leave, working nights etc.)

We know that hospital rotas make it impossible for all hospital trainees to attend our Half Day Release programme every Tuesday afternoon. We therefore run an additional programme of modular Wednesday courses and ask the trainees to make up the attendance requirement from a mixture of modular days and half-day release sessions. All the modular days are mandatory and (except the Induction course) each is run twice, so that all the trainees can attend them. The overall attendance requirement works out at a minimum of 56 hours, or 8 full days, or 16 half days, made up from both kinds of session.

This educational attendance requirement is recorded for each post in the Form B which is the equivalent of an educational contract. If our posts fail to meet this requirement, they may not be accredited for GP training.

DISCLAIMER: Medical information on this website is provided "as is" without any representations or warranties, express or implied. Bradford VTS does not warrant that the medical information on this website is complete, true, accurate, up-to-date or non-misleading. It is provided for educational purposes only and not as medical advice.